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<title>Accident/Occupation Claim Information</title>
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<div id="ClaimTitle">Accident/Occupation Claim Information</div>

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				<td width="200px">A) Accident or Illness due to employment? </td>
				<td><input type="radio" name="aoi" value="yes" /> Yes 
				<input type="radio" name="aoi" value="no" /> No </td>
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				<td width="100px">B) Injury due to auto accident? </td>
				<td><input type="radio" name="iAuto" value="yes" /> Yes
					<input  type="radio" name="iAuto" value="no" /> No </td>
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				<td width="200px">C) Description of how accident or work-related illness/injury occurred </td>
				<td><textarea rows="10" cols="40" name="injDesc"></textarea>
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				<td width="200px">D) Date of Accident or Beginning of Illness  </td>
				<td><input type="text" name="doi"></td> 
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				<td colspan="2" style="text-align:center"><a href="#">Continue</a> 
		
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